8 Fundamentals of Edema

Management

E
Aida E. Olvera-Dyckes dema (oedema) is a common condition after upper extremity injury or surgery.
Dorsal hand edema causes the skin to tighten, forcing the metacarpophalangeal
(MP) joints into hyperextension and the interphalangeal (IP) joints into flexion.
As a consequence, the collateral ligaments of all the joints tighten and the volar plates of
the proximal interphalangeal (PIP) joints shorten. The arches of the hand are lost and the
thumb becomes adducted and extended.

    Clinical Pearl

Without early intervention from a therapist, the anatomical
response to hand edema can result in fixed contractures with
fibrotic changes of tissues and shortening of musculotendi-
nous units.

Edema versus Swelling

Many people use the terms swelling and edema interchangeably, but they are not techni-
cally synonymous. Swelling is an enlargement of tissue that can occur for many reasons,
for example a tumor, excess fluid, infection (pus), or inflammation. Edema refers specifi-
cally to an excessive amount of fluid in the interstitial space (space between the cells). So,
edema manifests as swelling. Hand edema is not seen by the naked eye until interstitial
fluid volume has increased over 30% beyond normal.1

    Clinical Pearl

Localized swelling due to hemorrhage or infection is not
edema.

Edema is often described relative to its mechanism of injury, location, and pathogen-
esis. There are several classifications of edema, including acute, mild, brawny, pitting,
and lymphedema. This chapter focuses on peripheral edema, which is the edema that
occurs in the extremities.

Biological Mechanism of Edema Formation

There is normally a balance of fluid moving into and out of the vessels on a cellular level.
This balance is based on Starling’s equilibrium, which refers to the movement of fluid
across capillary walls and which is affected by hydrostatic pressure and oncotic pressure
in the capillaries and in the interstitium. The movement of fluid is usually balanced so
that there is a steady state in the sizes of the intravascular and interstitial compartments.
Edema occurs when the balance is disrupted.2 If either the capillary hydrostatic pressure
increases and/or the oncotic pressure is reduced, more movement of fluid from the intra-
vascular to the interstitial spaces will take place. 

Edema Related to Wound Healing

One of the most important tasks of managing wounds and edema is identifying inflam-
mation. Inflammation may be a sign of infection and presents as a localized area of soft-
tissue redness and swelling. The area is often warm to the touch and painful. When an
infection is suspected, the therapist should alert the physician immediately. In the presence

of infection, therapeutic intervention should be paused until the
therapist has clearance from the physician to continue treating.
Physical agent modalities, manual edema mobilization, and many
other treatments are contraindicated when there is infection. 
Types of Edema
Pitting edema is present when the pressure of a finger makes
an indentation that persists after the finger pressure is removed.
The indentation is not permanent; the depression slowly refills
with fluid from the surrounding tissues. Pitting edema may be
related to problems with the kidneys, heart valves, and low pro-
tein levels.3 It can also be caused by trauma, localized problems
with the veins, pregnancy, and certain medications. This type
of edema is often simply due to an accumulation of water and
is easily treated with movement, cold modalities, elevation, and
light compression.
Nonpitting edema (also known as brawny edema) is firm to
the touch because the tissue is fibrotic. When chronic, the skin
in the involved area can become thickened and brown in color.
Nonpitting edema is composed of fluid that is more protein-rich
and static––making this type of edema more difficult to treat.
Lymphedema is a condition that occurs when lymph fluid
has difficulty draining properly due to damage or a blockage
in the lymphatic system. This type of edema can be either pit-
ting or nonpitting. The lymphatic network can be altered by
infection, radiation therapy, surgery, parasitic infection, and
trauma. With lymphedema, protein-rich fluid accumulates in
the interstitial spaces of the skin and subcutaneous tissue. This
condition is incurable but it can be managed with appropriate
treatment. Manifestations of chronic lymphedema are abnormal
skin changes and an increased risk of infection. Complications
are more common in clients who are unable to obtain proper
medical care.  molecules are too large to be reabsorbed through the arterio-
Measuring Edema
Edema can be measured using volumetry, figure-of-eight mea-
surement, or circumferential measurement.1
Volumetry: This is a method of determining the volume of a hand
or arm by immersing the limb in a container full of water and
then measuring the amount of water that is displaced.
Figure-of-Eight: This method of measuring edema utilizes a flex-
ible tape measure. The therapist wraps the tape measure
around the hand in a figure-of-eight pattern at specific ana-
tomical landmarks.
Circumferential Measurement: This method uses a flexible tape
measure. The therapist wraps the tape measure once around
the hand/limb in a circular pattern at specific anatomical
landmarks.
Volumetric measurement is considered the gold standard
for measuring edema. Both the figure-of-eight and circumferen-
tial techniques are useful when it is not appropriate to immerse
the limb in water (for example, if there is a wound). By placing
a thin gauze covering over the wound, the therapist is able to
obtain a measurement while protecting the wound. However,
one of the problems with these two methods is that therapists
use varying amounts of force when pulling the tape measure
around the hand/limb. To address this problem, some thera-
pists use a force gauge to standardize the force applied to the
tape measure.
Fundamentals of Edema Management    CHAPTER 8 101
    Clinical Pearl
Edema can fluctuate due to factors such as activity level, time
of day, and fluid retention. To most objectively measure
changes in edema, try to have the same therapist measure the
client at the same anatomical position, using the same meas-
uring tool, at the same time of day.
Edema Management
Edema can be treated using a variety of techniques including
elevation, active range of motion (AROM), manual edema mobi-
lization, compression, taping, and modalities.
Elevation: Elevation of the limb is commonly recom-
mended for individuals with upper extremity edema. Elevation
helps because gravity assists with fluid drainage. The most effec-
tive position for upper extremity elevation is as follows: elbow
higher than the shoulder, wrist higher than the elbow, and hand
higher than the wrist. Additionally, the elbow should be more
extended than flexed. This position for elevation should be used
as long as it is not medically contraindicated. This sequential
positioning pattern creates a pathway for fluid drainage.
AROM: Active movement promotes fluid drainage and dis-
courages the formation of adhesions. The type and frequency of
AROM exercises should be customized to each client’s injury/
surgery and medical contraindications.
Manual Edema Mobilization (MEM): This technique treats
edema based on the anatomy and physiology of the lymphatic
system. The lymphatic system is the only pathway for interstitial
proteins to return to circulation and it is a key player in fluid
homeostasis.4 Interstitial fluid persists due to protein molecules
that attract water. At 6 to 12 days postinjury or surgery, these
venous system. Therefore they must be returned through the
lymphatic system. MEM includes light proximal-to-distal then
distal-to-proximal mobilization of the skin done in specific pat-
terns and segments, massaging over lymph node(s) proximal to
the edema, and promoting flow in the anatomic direction of the
lymphatic pathways. This facilitates the removal of excess fluid
and interstitial protein molecules that continue to attract water if
they are not recirculated.5
MEM can be very effective for clients with persistent edema
following upper extremity trauma or surgery who have intact but
overwhelmed lymphatic systems. It is not designed to be used
with clients who have damaged lymphatic systems or for clients
with primary lymphedema (a form of lymphedema not caused by
another medical condition). Contraindications for MEM include
infection, blood clots, congestive heart failure, renal failure, and
cancer.6,7
    Clinical Pearl
When using hands-on techniques to reduce edema, use very
light pressure (just enough pressure to gently move the skin).
Deep or heavy massage pressure collapses the lymphatic net-
work and is counterproductive or even injurious.
Compression: External compression provides counterpres-
sure and compensates for the lack of elasticity in edematous
tissues and thereby improves circulation. Compression helps
102 PART 1   Fundamentals
reinforce tissue hydrostatic pressure and facilitates venous and
lymphatic flow. Using compression in the acute phase of healing
is thought to limit the amount of space available for excess fluid
to accumulate during the fibroblastic phase of healing. Compres-
sion is thought to decrease the fibroblastic synthesis of collagen by
decreasing blood flood. This in turn causes local hypoxia, slowing
down the development of scar tissue and fibrosis. In the later
stages of healing, compression assists with edema management by
reducing net filtration. Compression wrapping of brawny edema
softens fibrotic connective tissue and scar tissue.
Contraindications to the use of compression include severe
arterial insufficiency, deep vein thrombosis, heart failure, uncon-
trolled hypertension, severe peripheral neuropathy, and active
tuberculosis.
Be aware that compression that is too tight actually dam-
ages the lymphatic system. A well-fitted compression garment
promotes light skin traction during active movement, and this
stimulates lymphatic flow. If creases are still visible in the skin 20
to 30 minutes after removing an edema glove or elastic tubular
stockinette, then the compression is too tight and a looser-fitting
garment should be used.  pressure differential underneath the skin, allowing for improved
Types of Compression
Edema Gloves: Edema gloves provide gentle compression. These
gloves are typically fabricated from nylon and spandex. The glove
should provide 15 to 25 mm Hg pressure in order to stimulate
the superficial lymphatic system, promoting edema reduction.
Custom and off-the-shelf gloves in various sizes are available.
Gloves should be designed to extend only to the middle pha-
langes to allow sensory input and integration of the hand into
activities of daily living. It is very important that gloves not be too
tight, especially at the distal edges, as this can cause worsening of
distal edema.
Elastic Tubular Stockinette: Elastic tubular stockinette pro-
vides gentle compression. It is made of a cotton/rayon blend with
rubber latex yarn. Caution should be used with clients who have
latex allergies. The elastic tubular stockinette can be cut to size.
Edema gloves and elastic tubular stockinette are reusable.
Clients can wash the garments with warm soapy water and then
air-dry them. These garments are often used for general edema,
burns, strains, sprains, and soft-tissue injuries. Elastic tubular
stockinette can be worn in combination with an edema glove. It
is common practice to give the client two pairs of edema gloves
and two sets of elastic tubular bandages, one to wash and one
to wear. It is important to closely monitor the skin for marks
indicating that the garments are too tight. A safe guideline is that
therapists should be able to get their finger inside a tubular sleeve.
If you can’t, it is too tight.6,8
String Wrapping: String wrapping is an outdated edema
management technique that is still sometimes used and therefore
deserves to be mentioned. It was originally thought to be a way of
using distal to proximal compression to move edema out of the
hand. However, we now know that the terminal portion of the
lymphatic system is very delicate. Too much pressure, such as the
pressure used with string wrapping, damages the lymphatic tissues.
For this reason, string wrapping should not be used.
Short-Stretch Bandaging: Short-stretch bandages stretch
20% of their original length. In this way they differ from ACE
elastic bandages, which stretch 140% to 300% of their original
length. Short-stretch bandaging is a compression technique used
to manage lymphedema. It is also used in manual edema mobi-
lization. The techniques of use exceed the scope of this chapter,
but readers are encouraged to pursue outside information about
the use of short-stretch bandaging in the treatment of edema.
Kinesiology tape: Kinesiology tape can be applied to increase
lymphatic and vascular flow, thereby reducing edema and dimin-
ishing pain. The tape is thinner and more elastic than conven-
tional tape and can be stretched 120% to 140% of its original
length. Kinesiology taping is designed to raise the epidermis,
reducing the pressure on the mechanoreceptors below the der-
mis. This is proposed to reduce pain. Kinesiology tape is reported
to have a beneficial effect on lymphatic and venous circulation
by raising the epidermis, thereby decreasing the pressure in the
dermis and promoting lymphatic drainage through its mechani-
cal action during movement. The theory is that when applied on
stretch, kinesiology tape can lift the skin away from the muscle,
creating space between the layers of fascia. Blood vessels, lym-
phatic vessels, and certain nerves are found in the fascia. By lift-
ing the skin away from the muscle, kinesiology tape changes the
perfusion of the area with ground substance, which includes the
water and proteins responsible for the lubrication and nutrition
of the connective tissue cells. Contraindications include allergic
reactions to adhesive tape, open wounds, presence of a deep vein
thrombosis, infection, peripheral neuropathy, and active cancer.9
Contrast Baths: It has been suggested that contrast baths pro-
duce a “pumping effect” contributing to edema reduction. The
rationale provided is that contrast baths may help reduce pain
and stiffness by activating vasodilation and vasoconstriction via
muscle contraction.10 However, a randomized controlled study
of contrast baths on patients with carpal tunnel syndrome did not
find any significant effect on hand volume with use of contrast
baths.11 A systematic review of the effectiveness of contrast baths
concluded that although its use may increase the temperature of
skin and blood flow superficially, there was conflicting evidence
on its effect on edema.12 Contraindications for use of contrast
baths include open wounds, poorly controlled epilepsy, hyper-
tension, and diabetes.
Intermittent Pneumatic Compression (IPC): IPC is often a
modality of choice for treating lymphedema. It can also be effec-
tive for reducing posttraumatic edema, especially in the inflam-
matory phase of healing.13 The pump consists of a sleeve with
multiple pressure compartments that encompass the entire limb.
Once placed on the extremity, the chambers of the pump are
sequentially inflated, working distal to proximal. This sequen-
tial compression moves the edematous fluid into the lymphatic
system, which in turn pushes the venous blood proximally.
The pumping motion encourages normal circulatory action by
stimulating extracellular drainage and fluid clearance. Contrain-
dications include congestive heart failure, deep vein thrombosis,
inflammatory phlebitis, a history of pulmonary embolism, active
infection, lymphangiosarcoma, and nonhealed fracture.
Electric Stimulation: Muscle contractions are imperative
for lymphatic flow. When a client is unable to perform effective
active muscle contractions to assist in the drainage of the lym-
phatic and venous systems, electric stimulation can be helpful.
Muscle contractions stimulate venous and lymphatic circulation.
Current intensity must be high enough to elicit a muscle contrac-
tion. The client should be encouraged to actively contract their
muscles simultaneously with the electrical stimulation. Treatment

time is usually 20 minutes, with a cycle of 5 seconds on and 5
seconds off. High-voltage pulsed current and medium-frequency
alternating current are commonly used. Contraindications are
pregnancy, cancer, cardiac pacemaker or other implanted electri-
cal stimulators, active tuberculosis, thrombophlebitis, thrombosis
over the carotid sinus, and active hemorrhage.14
Cryotherapy: Cold therapy is often beneficial for the reduction
of acute edema, especially in the inflammatory phase of healing.
Cold therapy includes ice packs, gel wraps, and cold-water baths.
Physiological exposure to cold activates vascular permeability, pro-
motes vasoconstriction, and reduces local blood flow. This in turn
decreases prostaglandin synthesis and histamines, thus reducing
swelling and pain. Contraindications include but are not limited to
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Fundamentals of Edema Management    CHAPTER 8 103
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regeneration, impaired circulation, and chronic wounds.1 
Summary
This chapter has presented a selection of techniques commonly
used to treat edema. Elevation and appropriate active movement
are very powerful methods to prevent and reduce edema. Edema-
reducing modalities are an adjunct to treatment and must be
selected cautiously using sound clinical reasoning. Edema control
is key to successful clinical outcomes and should be among the
highest of priorities in the hand therapist’s plan of care.
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of cointrast baths on patients with carpal tunnel syndrome, J Hand Ther
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